Jose Rizal University College of Nursing Presented to the Faculty of Jose Rizal University College of Nursing

Presented by: BSN III Section A301N Group 1A and 1B

NURSING CARE MANAGEMENT OF PATIENT WITH CHOLELITOTHIASIS

Intraoperative and postoperative

Definition of terms
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholelithiasis is the presence of gallstones in the gallbladder Cholecystectomy is a treatment that cures gallbladder disease is surgical removal of the gallbladder.

Biliary System :
consists of the organs and ducts (bile ducts, gallbladder and associated structures) that are involved in the production and transportation of bile. Functions of the biliary system: to drain waste products form the liver into the duodenum and to help in digestion with the controlled release of bile.

Risk factors associated with development of gallstones

Heredity Obesity Rapid weight loss through diet Age over 60 Female gender Women with high estrogen levels Multiple pregnancy Hormone replacement therapy Use of birth control pills, Prolonged fasting and low-fiber diet High-cholesterol and high-starch diets

Symptoms of Gallbladder disease

1) Frequent bouts of indigestion 2) Nausea and bloating 3) Attacks of sharp pains in the upper part of the right abdomen. 4) Jaundice (yellowing of the skin).

Purpose and Objectives

General Objective:
The study aims to render nursing care of a client who undergone open cholecystectomy and determine the appropriate intervention to be done.

Purpose and Objectives

Identify and analyze factors that led to the development of the gallstones. To discuss the relevant interventions that was utilize to resolve the condition Perform complete history and physical exams, consultations, and postoperative checks. Management of the postoperative patient and assess for postoperative complications Reestablish patients physiologic equilibrium, alleviate pain and teach patient self-care. To note whether the interventions done were effective in helping the patients condition.

CHAPTER I
ASSESSMENT

Nursing Health History Biographic Data

Patient s Initials Age Gender Civil Status Birthdate Birthplace Address Religion Occupation Nationality Date Admitted Date Interviewed Final Diagnosis

: : : : : : : : : : : : :

J.A.C. 31 years old Female Married January 12, 1979 Marikina City Pasig City Roman Catholic Housewife Flipino June 28, 2011 June 30, 2011 Cholecystolithiasis

CHIEF COMPLAINT
Client experiencing intense pain at the right upper quadrant that radiates into her back, pain scale of 8/10.

History of Present Illness:

During her 8th month of conception patient experience epigastric pain, that prompt her to consult her obgyne. cholecystitis was seen on her and was prescribe Tramadol 5mg. For pain. After 1 another intense pain was felt that bring her San Juan Medical hospital . April 6,2011 when she was dx. Of having multiple cholecystolithiasis. 7 days prior to her Admission (June 21, 2011) patient underwent different Laboratory exams, She was admitted june 28, 2011, and was scheduled for surgery open cholecystectomyjune 29,2011

Past Medical History:

Client sometimes had common cough and cold but didn t mind to consult to a doctor. She was fully immunized during her childhood, no allergies and illnesses reported.

Obstetric History:
Her last hospitalization was September 26, 2000 when she delivered a twin baby via caesarian due to prolonged labor. Client is married and her first pregnancy is when she was 21 years old, client OB history G3P4, T=3, P=0, A=0, L=4, M=1. She never used any contraceptives,

OPERATING ROOM

RECOVERY ROOM

SURGICAL WARD

GENOGRAM

Review of System Subjective Data:

GORDONS PATTERN OF FUNCTIONING

 Health Perception Pattern Nutrition Metabolic Pattern Elimination Pattern Activity- Exercise Pattern Sleep -Rest Pattern Cognitive-Perceptual Pattern

 Sensory Perceptual Pattern Self-Perception Pattern Role-relationship Pattern Sexual Reproductive Pattern Coping- Stress Pattern Value- Belief Pattern

Physical Assessment
METHODS NORMAL ACTUAL FINDINGS INTERPRETATION ANALYSIS

1.GENERAL Inspection Healthy APPEARANCE appearance, no body odor, well groom cooperative, able to follow instructions, good posture and gait.

Body malaise, restlessness, weakness and discomfort, interactive.

Abnormal General appearance of the patient provides cues to the illness, severity of the diagnosis and the patient s values, socio economic status and personality.

10. SKIN

Inspection Intact, smooth and even, light to brown skinned, no edema and tenderness.

Peripheral skin is intact and smooth. There is no presence of edema.

Abnormal Decreased perfusion and due to vasoconstric tion.

11. NAILS

Inspection Curved nails Curved nails (160),clean. (160), clean and short, (+) capiliary refill test. (1-3 secs.)

Ref.Medical Surgical Nursing 11th edition by Brunner and Suddarths. P. 1935 vol.2

Laboratory Examination Results:

Ultrasonography X-Ray Electrocardiogram Blood Chemistry Hematology CBC (Complete Blood Count) Urinalysis

Results:
Abdominal Ultrasound Date April 6, 2011

- Multiple cholecystolithiasis, with associated bile sludge. Mildly dilated CBD, most likely due to distal biliary obstruction.

Blood Chemistry Result Alkaline Phosphate SGPT Amylase 52.2 13.14 9

Date: June 21, 2011 Unit u/L u/L u/L Normal Range 35 129 10 - 40 28 100

Creatinine
Lipase

42.81
o.

Umol/L
u/L

45 84
13 - 60

Hematology Prothrombin Time Control Patient APTT Control Patient

Date: June 26, 2011

13.0 14.1

Seconds Seconds

29.8 34.0

Seconds Seconds

CBC (Complete Blood Count)

Date: June 21, 2011

Result Hemoglobin Hematocrit Red Blood Cell White Blood Cell Platelet 125 0.38 4.22 12.40 235

Unit g/L

Normal Range 120 160 0.36 0.4

X10^12/L X10^9/L X10^9/L

4.20 5.40 4.50 10.0 140 - 440

Differential Count: All Normal

Anatomy and Physiology

BILIARY SYSTEM
consist of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. Functions of the biliary system: To drain waste products from the liver into the duodenum To help in digestion with the controlled release of bile

Anatomy and Physiology

GALLBLADDER
The gallbladder (or cholecyst, sometimes gallbladder) is a small organ whose function in the body is to harbour or store bile and aid in the digestive process.

2 Types of Gallbladder stones

1. Cholesterol stones - are usually yellowgreen and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones.

2. Pigment stones - are small, dark stones made of bilirubin

Book Based Pathophysiology

Patient Based Pathophysiology

Precipitating Factors: >too much intake of salty foods >too much intake of fatty foods >Alcohol drinking RISK FACTOR Predisposing Factors: >Age >Gender: female 4x higher risk than male. >Multiple Pregnancy

System involved: Biliary System (Gallbladder) .

Other involvement: Decreased ADLs

Etiology: Presence of gallstones.

Anatomical/physical change: >Mildly dilated Common Bile Duct >Distended gallbladder.

Physiologic Manifestations: Poor emulsification of fat molecules Laboratory Tests: Clinical Manifestations: >RUQ Pain >Discomfort >Biliary Obstruction >Abdominal ultrasound (Multiple cholecystolithiasis with associated bile sludge. Mildly dilated CBD most due to distal biliary obstruction.) >X-ray >Electrocardiogram >Hematology >Complete Blood Count (Increase WBC) >Urinalysis

Final Diagnoses: >Multiple Cholecystolithiasis

Surgical Management: >Open Cholecystectomy with IOC

PLANNING
List of Identified Nursing Diagnosis According to Priority

Prioritized Problem

1. Pain (high priority 1)

Classification Justification Actual problem This is an actual problem under the physiological needs of Maslows hierarchy of needs. This problem needs immediate intervention since pain is the initial discomfort a client notices after the anesthesia wearoff. This condition could also occupy the thinking of a person and may result to poor physical functioning. This problem gives the client unpleasant sensory and emotional discomfort.
Ref: Text Book of Basic Nursing, by C.B. Rosdahl, pg. 759; Nurses Pocket Guide, by M.E. Doenges, pg. 498

2. Impaired physical Actual problem This is an actual problem that restricts or disrupts the normal physical function of the body and some essential activity that is needed to meet mobility clients physiologic needs in Maslows Hierarchy of needs. (moderate priority 2)
Ref: Nursing Process, concept and Application, by Wanda Seaback pg. 54

3. Risk for infection Potential problem This potential problem belongs to the safety and security needs according to the Maslows Hierarchy needs. The problem can be easily (Low priority 3)
modified through proper health teaching of proper hand washing technique, wound care, and environmental modifications. This intervention may lead to resolving other problems.
Ref: Nursing Process, concept and Application, by Wanda Seaback pg. 54

NURSING CARE PLAN # 1

Assessment Subjective cues:

NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS Damage tissue (surgical incision)

PLANNING Goal: After the nursing 30mins. of intervention patient will be able to demonstrate a decrease/reduce level of pain in the incision area Pain scale from 8/10 to 4/10

NURSING INTERVENTION Independent: 1.Assess patient vital signs. 2.Place patient in a upright position or semi fowlers position. 3.Encourage patient to perform deep breathing exercise. 4.Instruct the patient and significant others to have diverting activity such as: a. watching TV b. listening to music 5.Demonstrate proper application of hot and cold compress application. Dependent: >Administer Tramadol 30 gtts/min as prescribed by the physician. Collaborative: Refer to pain control management unit

RATIONALE

EVALUATION

Masakit ang tahi ko Acute pain lalo na pag R/T surgical incision nagagalaw . Due to dilatation As verbalized by the of small bld vessels mother w/in damage area (RUBOR)

>To obtain baseline data

>These position facilitate lung expansion and to prevent compression of incision area. >muscle relaxation alleviate pain.

After 30mins. of nursing intervention the client was able to: a. Verbalized that the pain was reduces as evidence by pain scale 0f 4/10 b. Enumerate nonpharmacologic methods to relieved pain. c. Demonstrate relaxation techniques.

Objective cues: >Guarding behaviour >body malise >facial grimace >decrease mobility >irritable V/S BP: 140/90 RR: 23 cpm PR: 97bpm T: 37.3 c P/S : 8/10 Increase bld flow vasodilation deliver warm bld. (CALOR)

>To provide distraction of attention to pain and will provide relaxation at the same time.

Fluid shifting into vascular space (TUMOR)

>To prevent swelling and hematoma.

d. Maintain rest and relaxation period.

Stretching of and distortion of tissue due to inflammatory chemical mediator e.g. B,P,S induce pain (DOLOR)

>a centrally acting medication to relieve pain.

>for more pain control information

NURSING CARE PLAN #2

ASSESSMENT Subjective Cues:

NURSING DIAGNOSIS SCIENTIFIC ANALYSIS

PLANNING

INTERVENTIONS INDEPENDENT: 1. Asses level of phisical mobility

RATIONALE

EVALUATION

Masakit ang tahi Impaired physical ko lalo na pag mobility r/t surgical nagagalaw . As incision verbalized by the client.
Objective Cues: >body malaise >facial grimace >decrease mobility (limited range of motion) >poor posture

Surgical incision

After 1 day of nursing interventions the patient will be able to: a.determine ways on how to improve phisical activities

Released of chemical mediators

1.Enable the nurse to idetify responses to problems & difficulties in immobility 2. Early ambulation will aide for proper circulation of blood in to the heart and lungs.

After 1 day of nursing interventions the patient enable to demonstrate resumption of ADLs. Goal was met

Pain felt from incision b.demonstrate area during body different activities movement that enable resumption of activities. Limits normal activities .

2. Instruct patient and S/O to ambulate pt. as soon as possible and increase distance each time.

3. Discuss to patient 3. To promote and S/O to have restoration of body proper resting and energy and gain sleeping time.
strength.

Impaired physical mobility

DEPENDENT: >Administer medication as prescribed by the physician.

>To make healing process faster.

NURSING CARE PLAN # 3

ASSESSMENT SUBJECTIVE CUE/S: N/A NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING GOAL: After 2 hours of nursing intervention patient & SO will be able to verbalize understanding about infection control. OBJECTIVE: After 2 hours of nursing intervention, patient & SO will be able to: a.Understand on how to prevent infection. b.Demonstrate proper hand washing & wound care technique. INTERVENTION INDEPENDENT: 1.Assess signs of infection such as redness, swelling, tenderness. 2. Discuss ways on how to prevent occurrence of infection Such as: >check OS if wet >regular changing of wound dressing. >taking medication on time. RATIONALE EVALUATION After 2 hours of nursing intervention, the patient verbalize understanding on different risk factors of infection, and ways to prevent it.

Risk for infection related to post surgical OBJECTIVE CUE/S: incision. Presence of Surgical wound

Surgical incision

-to gain baseline data.

Damaged tissue

-knowledge improves understanding.

Possible entry of pathogen

Goal was met.

Risk for infection

3. Demonstrate to client and SO to wash hands before and -Hand washing reduces the risk for infection. after cleaning the incision site. 4. Encourage patient to take the full course of antibiotics -Not completing the entire even if symptoms improve or course of the prescribed antibiotic regimen can lead to disappear. drug resistance. DEPENDENT: 1.Administer antimicrobial (antibiotic) drugs as ordered. COLLABORATIVE: 1.Refer to nutritionist. Antimicrobial drugs are either toxic to the pathogen or retard the pathogen s growth. -for proper nutrition on increasing immune system to reinforce fast wound healing.

Medical Management DRUG STUDY

Genric Name Atracurium Besylate Metoclapra Ranitidine Hydrochloridemide Sensorcaine, Marcaine Tramadol Hydrochloride Zinacef

Brand Name Tracurium Clopra Zantac Bupivacaine HCL Ketorolac Cefuroxime

 Instruct patient and S/O to continue taking the prescribed medications, such as: Cefuroxime - 1 tab. 3xday Per Orem for 10 days Tramadol - 1 tab. Per Orem As needed Ranitidine - 1 tab. Per Orem as needed

Treatment
Instruct patient and S/O to continue taking the prescribed medications, such as: Cefuroxime 1 tab. 3xday Per Orem for 10 days Tramadol 1 tab. Per Orem As needed Ranitidine 1 tab. Per Orem as needed

Diet/ Activity/ Exercise Encourage to avoid high cholesterol food. Encourage to maintain Fluid and electrolyte balance Low fat, low salt for 4 to 6 weeks. Encourage eating proper and balanced diet which includes fruits and vegetables. Every morning the patient should perform physical exercise. Encourage deep breathing exercise Encourage 5-10 minutes walking everyday Avoid sit-ups. Could only return to her routine if the wound is totally healed which usually occur after 4 to 6 weeks.

The gallbladder may be removed in one of two ways:

Open Method: In this method, a two- to three- inch incision is made in the upper right-hand side of the abdomen. The surgeon locates the gallbladder and removes it through the incision.

Laparoscopic Method This procedure uses several small incisions and three or more laparoscopes-small thin tubes with video cameras attached- to visualize the inside of the abdomen during the operation. The surgeon performs the surgery while looking at a T.V monitor. The gallbladder is removed through one of the incisions

SURGICAL MANAGEMENT

Cholecystectomy - is the surgical removal of the gall bladder, an organ located just under the liver on the upper right quadrant of the abdomen. The gallbladder stores concentrates bile, a substance produced by the liver and used to break down fat for digestion.

Reasons for the procedure

An open Cholecystectomy may be performed if the gallbladder contains gallstones (cholecystitis) is is inflammed or infected (cholecystitis), or is cancerous.

Reasons of the Procedure

As with any surgical procedure, complications may occur. Some possible complications of cholecystectomy may include, but are not limited to the following: Bleeding Infection Injury to the bile duct the tube that careries bile from the gallbladder to dthe small intestine

Before the Procedure

 Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the problem. You will be ask to sign a consent form that gives you permission to do the test. Read the form carefully and ask questions if something is not clear. In addition to a complete medical history, your physician may perform a physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood or other diagnostic tests. You will be asked to fast for 8 hours before the procedure, generally after midnight. If you are pregnant or suspect you may be pregnant, you should notify your physician. Notify your physician if you are sensitive to or are allergic to any medications, latex, tape and anesthetic agents (local and general) Notify your physician of all medications (prescribed and over-the counter) and herbal supplements that you are taking.

 Notify your physician if you have a history of bleeding disorders or if you are taking any anti-coagulant (blood-thinning) medications, aspirin or other medications that affect blood clothing. It may be necessary for you to stop medications prior to the procedure. If your procedure is to be done on an outpatient basis, you will need to have someone to drive you home afterwards because of the sedation given prior to and during the proceddure. The area around the surgical site may be shaved. Based upon your medical condition, your physician may request other specific preparation.

Open Method Colecystectomy

 An incision (open method) will be made. The incision may slant under the ribs on the right side of the abdomen, or it may be an up- and down- incision in the upper part of the abdomen. The gallbladder is removed. In some cases, one or more drains may be inserted through the incision to allow drainage of fluids or pus.

Procedure completion, both methods:

The gallbladder will be sent to the lab for examination. The skin incision/s will be closed with stitiches or surgical staples . A sterila bandage/dressing or adhessive strips will be applied.

After the procedure

 After the procedure you will be taken to the recovery room for observation. Your recovery process will vary depending upon the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. You may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line. You may have a thin plastic tube inserted to your nose into your stomach to remove air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or eat until the tube is removed.

 You may have one or more drains in the incision if an open procedure was done. The drains will be removed in a day or so. You might be discharged with the drain still in your abdomen covered with a dressing. Follow your physician s instructions for taking care of it. You will be encouraged to get out of bed within a few hours after a laparoscopic procedure, or by the next day after an open procedure. Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually advanced to more solid foods as tolerated. Arrangements will be made for follow-up visit with your physician, usually two to three weeks after the procedure.

At home

 Once you are home, it is important to keep the incision clean and dry. Your physician will give you specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall of within a few days. The incision and the abdominal muscles may ache, especially after long periods of standing. Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications. Walking and limited movement are generally encouraged, but strenuous activity should be avoided. Your physician will instruct you about when you can return to work and resume normal activities.

Notify your physician to report any of the following: Fever and/or chills Redness, swelling or bleeding or other drainage from the incision site/s Increased pain around the incision site/s Abdominal pain, cramping, or swelling Pain behind the breastbone.

EVALUATION

A.

DISCHARGE PLANNING INSTRUCTIONS

Medication
Continue taking the following prescribed medication to obtain the complete effectiveness: Cefuroxime more Tramadol 500g 1tab 3xday orally for 10 Days

50mg 1tab as needed

Exercise
Every morning the patient should perform light physical activities e.g. Brisk Walking 10 mins. /day, gradually increase each time. Encourage coughing and deep breathing exercise to prevent atelactasis NOTE: Give the pain reliever before doing the exercise

Treatment Daily wound care Finish full course of antibiotics.

Health Teaching
Instruct the patient to clean the wound every morning or if necessary Instruct the patient to avoid heavy lifting for 4-6 weeks Instruct the patient to avoid over the counter drugs that may interfere with the current medication Emphasize proper oral and body hygiene

Outpatient
Instruct patient and significant others to have a follow up check-up 4 days upon discharge or, on the specific date given by the physician

Diet
Instruct the patient to avoid high cholesterol food e.g. fast foods, street foods, junk foods (chips) Instruct patient to take low salt and low fat diet. Sample Meal: Steam fish Fresh/steam vegetables Fruits, 1-2glass of water Instruct the patient to increase fluid intake to maintain fluid and electrolyte balance